Provider Demographics
NPI:1528752300
Name:ICU423R
Entity type:Organization
Organization Name:ICU423R
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIUP
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-730-6438
Mailing Address - Street 1:202 E EARLL DR STE 360
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2677
Mailing Address - Country:US
Mailing Address - Phone:480-788-5621
Mailing Address - Fax:480-779-1277
Practice Address - Street 1:1101 W GUADALUPE RD STE 1
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-7601
Practice Address - Country:US
Practice Address - Phone:480-788-5621
Practice Address - Fax:480-779-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty